ITS  CAUSE,  PREVENTION 
AND  CURE 


ijpi 

[.&:  - 


UNITED  FRUIT  COMPANY 
BOSTON,  MASS. 


MALARIA 

Its  Cause,  Prevention 
and  Cure 


' By 

W.  E.  DEEKS,  M.D. 

General  Manager 
Medical  Department 

UNITED  FRUIT  COMPANY 


Published  by 

United  Fruit  Company 

One  Federal  Street,  Boston,  Mass. 


INTR  ODUCTION 


Malaria  is  widely  distributed  throughout  the  littoral  and  other 
low-lying  areas  of  tropical  and  subtropical  countries  of  the  world, 
wherever  the  rainfall  is  sufficient  to  leave  standing  water  in  which 
anopheles  mosquitoes  can  breed.  The  extreme  latitudes  where  it  has 
been  encountered  are  40"  South  and  60°  North. 

Our  knowledge  of  the  clinical  manifestation  of  malaria  goes  back 
to  antiquity.  Hippocrates  differentiated  malaria  fevers  from  con¬ 
tinuous  fevers,  and  recognized  the  periodicity  of  the  malarial  parox¬ 
ysms,  dividing  them  into  quotidian,  tertian  and  quartan. 

No  specific  remedy  for  the  treatment  of  malaria  was  known  in  Europe 
until  1640,  when  the  Countess  del  Cinchon  introduced  cinchona  bark, 
which  was  named  after  her.  As  the  wife  of  the  Viceroy  of  Peru,  in 
1638  she  had  been  cured  of  an  intermittent  fever  by  a  preparation 
composed  of  this  bark.  And  today  the  only  specific  remedy  known  for 
the  cure  of  malaria  is  quinine  and  its  derivatives  prepared  from  cin¬ 
chona  bark. 

In  1880  Laveran  discovered  the  parasites  of  malaria  under  the 
microscope.  In  1894  Manson  suggested  the  theory  that  the  disease 
was  transmitted  by  mosquitoes.  And  in  1898  Ross  definitely  incrim¬ 
inated  the  anopheles  mosquitoes  as  the  transmitting  agents. 

In  addition  to  these  outstanding  discoveries,  increments  to  our 
knowledge  have  been  added  by  a  large  number  of  scientific  workers, 
and  today  most  of  the  facts  concerning  the  causation,  prevention  and 
cure  of  malaria  are  known.  With  our  present  knowledge,  there  is  no 
reason  why  an  intelligent  man,  familiar  with  the  data  and  the  means 
available  to  protect  himself,  should  contract  malaria.  Enormous  areas 
throughout  the  world  where  malaria  was  at  one  time  endemic  have  been 
so  far  freed  from  infection  that  it  has  ceased  to  be  a  serious  prob¬ 
lem,  and  in  many  of  those  areas  malaria  no  longer  exists. 

These  results  have  been  obtained  largely  through  drainage  and 
cultivation  of  the  soil.  By  these  methods  the  breeding  places  of  mos¬ 
quitoes  have  been  destroyed,  and  with  the  consequent  reduction  of 
malaria  the  tillers  of  the  soil  have  become  more  efficient  and  are  re¬ 
ceiving  greater  returns  for  labor  expended.  This  state  of  affairs  begets 
health  and  prosperity,  which,  in  turn,  mean  more  comfortable  homes, 
better  food  and  clothes,  improved  educational  facilities  and,  in  short, 


an  advance  in  the  physical  and  mental  status  of  the  inhabitants  of  the 
farming  communities,  so  that  they  are  able  to  help  themselves.  We 
must  direct  our  efforts  to  an  extension  of  such  methods  as  these  to 
districts  now  infected,  if  we  are  to  obtain  satisfactory  results. 

Mai  aria  districts  should  be  investigated  by  agricultural  experts, 
and  the  farmers  should  be  advised  as  to  what  crops  can  be  most  advan¬ 
tageously  cultivated  to  give  them  the  best  results  for  labor  expended. 
Naturally,  there  is  no  use  of  raising  good  crops  if  there  are  no  roads 
over  which  to  transport  them,  and  no  market  available  to  absorb  the 
produce.  To  this  end,  state  and  federal  assistance  is  necessary. 
Precedents  haA^e  been  established  by  the  reclamation  of  large, 
uninhabited  areas  for  agricultural  purposes.  Is  it  not  just  as  com¬ 
mendable,  and  infinitely  more  humanitarian,  to  spend  money  for  the 
reclamation  of  large  inhabited  areas,  and  thus  reclaim  not  only  the 
land  but  the  inhabitants  also?  The  inhabitants  are  the  chief  asset  of 


Geographical  distribution  of  malaria  (stitt) 


any  country.  Through  the  results  of  their  labor  prosperity  comes, 
and  the  more  efficient  they  are,  the  greater  the  returns. 

At  present,  the  fight  against  malaria  is  being  carried  on  largely 
by  individual  corporations  and  beneficent  organizations.  They  are 
waging  an  uphill  fight,  however,  and  their  efforts  to  give  the  best 
results  need  governmental  support.  If  we  enable  the  farmer  to  become 
prosperous,  furnish  him  with  school  facilities,  educate  him  in  matters 
relating  to  the  prevention  of  diseases  immediately  concerning  him — in 
other  words,  give  him  a  square  deal  and  afford  him  an  opportunity 
to  help  himself,  the  problem  of  malaria-control  will  be  solved. 

A  large  number  of  people  in  tropical  and  subtropical  countries 
labor  under  the  delusion  that  all  febrile  conditions  are  malarial  in  origin, 
and  take  quinine  indefinitely  irrespective  of  the  results.  This  is  a 
great  mistake.  Any  fever  which  does  not  yield  to  quinine  in  proper 


dosage  within  from  4  to  6  days  is  probably  not  due  to  malaria,  but 
has  some  other  underlying  cause.  I  wish,  therefore,  to  emphasize  the 
importance  of  consulting  a  physician  in  all  cases  of  fever  which  do 
not  yield  rapidly  to  the  administration  of  quinine. 

This  little  brochure  is  an  attempt  to  place  the  main  facts  concern¬ 
ing  the  cause,  prevention  and  cure  of  malaria  before  physicians,  sani¬ 
tarians,  social  workers,  school  teachers  and  intelligent  laymen  who 
wield  a  large  local  influence  in  their  respective  communities  to  the  end 
that  they,  having  informed  themselves,  may  enlighten  others. 

In  preparation  of  this  pamphlet  I  am  indebted  to  Doctors  Milton 
J.  Rosenau,  H.  R.  Carter,  S.  T.  Darling,  L.  D.  Fricks  and  J.  A.  Fer¬ 
rell,  who  kindly  read  the  manuscript  and  made  important  suggestions. 

For  illustrations,  I  am  indebted  to  Surgeon-General  E.  R.  Stitt 
and  his  publishers,  P.  Blakiston’s  Son  &  Company ;  to  Professor  F. 
Fiilleborn,  of  Hamburg,  Germany;  Dr.  J.  G.  Thomson,  of  London, 
England ;  Vittorio  Ascoli,  Bureau  of  Entomology,  U.  S.  Department 
of  Agriculture;  American  Museum  of  Natural  History;  and  Miss 
Mabel  Hedge,  of  the  Rockefeller  Institute. 

W.  E.  DEEIvS,  M.D. 

General  Manager 
United  Fruit  Company 
17  Battery  Place 
New  York  City 

February  16,  1925 


MALARIA 

ITS  CAUSE,  PREVENTION 
AND  CURE 


ALARI  A  is  a  disease  caused  by  three  closely  related  species  of 
minute  animal  parasites.  There  are  two  distinct  cycles  in 
their  development,  one  of  which,  the  nonsexual,  takes  place  in 
man,  in  whom  it  causes  the  disease  known  as  malaria ;  the  other,  the 
sexual  cycle,  takes  place  in  the  female  anopheles  mosquito. 

N  onsexual  Cycle  of  Development  of  the  Parasite 

When  the  young  parasites  (sporozoites)  are  injected  into  the  blood 
of  a  human  being  by  the  malaria-infected  mosquito,  while  feeding  on 
that  individual,  they  immediately  invade  the  red  cells  on  which  they 
feed  and  in  which  they  grow,  until  the  contents  of  the  invaded  red 
cells  are  consumed.  This  process  takes  from  48  to  72  hours,  the 
length  of  time  depending  on  the  species  of  parasite  involved.  During 
this  period  the  parasites  have  reached  maturity,  and  each  one  has 
become  divided  into  a  number  of  minute  bodies,  known  as  “spores.” 
The  spores  in  lower  forms  of  animal  and  plant  life  correspond,  in 
function,  to  the  seeds  of  the  grass  family  and  to  the  nuts  or  seeds 
of  fruit  trees.  Each  spore,  seed  or  nut  is  capable,  under  suitable  con¬ 
ditions,  of  growing  into  a  neiv  organism,  grass-plant,  or  tree.  By 
“sporulation”  is  meant  the  rupture  of  the  sac  containing  the  spores, 
which  are  thus  liberated. 

The  size  of  the  parasite  can  be  best  appreciated  when  we  consider 
that  a  red-blood  cell,  in  which  one  or  more  parasites  develop,  is  ap¬ 
proximately  1/3,200  of  an  inch  in  diameter  and  about  one  quarter  of 
that  size  in  thickness,  or  approximately  1/12,800  of  an  inch.  There 
are  about  5,000,000  red  cells  in  a  cubic  millimeter*  of  normal  blood, 
and  to  these  the  blood  owes  its  red  color. 

The  number  of  the  spores  produced  by  each  nonsexual  malaria 
parasite  varies  from  8  to  32,  and  they  entirely  replace  the  contents 
of  a  red  cell ;  its  wall  or  limiting  membrane  alone  remains.  This  wall 
then  ruptures,  liberating  the  spores  in  the  “plasma,”  or  fluid  contents, 

*A  millimeter  equals  about  1/25  of  an  inch. 

5 


MALARIA— ITS  CAUSE,  PREVENTION  AND  CURE 


of  the  blood.  Some  of  the  spores  are  “phagocyted,”  or  engulfed,  by  the, 
white  cells  of  the  blood  (this  process  being  one  means  of  getting  rid  of 
foreign  or  dead  material  in  our  bodies)  and  all  the  spores  not  destroyed 
by  this  and  other  defensive  agencies  of  the  body  invade  other  red  cells, 
and  repeat  the  same  method  of  growth — spore-formation  and  spol¬ 
iation — until,  by  geometrical  progression,  enormous  numbers  of  para¬ 
sites  develop. 

At  each  sporulation  a  toxin,  or  poison,  is  liberated,  and  this  is 
responsible  for  most  of  the  symptoms  produced.  Coincident  with  the 
nonsexual  development  of  the  parasites,  sexual  forms  of  the  organisms, 
(gametes,  or  gametocytes) ,  male  and  female,  are  developing  in  the  red 
cells.  They  require  about  twice  as  long  as  the  nonsexual  forms  to  reach 
maturity.  They  do  not  divide  and  form  spores  ;  but  when  mature,  each 
one  completely  occupies  a  red  cell.  Their  number  is  much  smaller  than 
that  of  the  nonsexual  parasites,  and  Darling  estimates  that  about  12 
must  be  present  in  a  cubic  millimeter  of  blood  before  the  number  is 
sufficient  to  infect  mosquitoes. 

The  Sexual  Cycle  of  the  Parasites 

The  female  anopheles  mosquito  must  have  a  meal  of  warm  blood  in 
order  to  mature  her  eggs,  and  man  serves  the  purpose;  but  some  species 
will  feed  about  as  readily  on  any  other  warm-blooded  animal,  domestic 
or  wild.  When  feeding  upon  a  malaria-infected  individual,  the  female 
anopheles  takes  into  her  stomach,  along  with  the  blood,  large  numbers 
of  parasites,  both  sexual  and  nonsexual.  The  latter  are  digested  and  dis¬ 
appear,  but  the  sexual  forms  develop.  The  male  gamete,  or  sexual  ele¬ 
ment,  throws  out  some  threadlike  extensions  (flagella)  one  of  which  en¬ 
ters  a  female  gamete  after  the  latter  has  undergone  some  changes  to 
make  room  for  it,  and  thus  the  female  becomes  fertilized  and  proceeds 
to  further  development.  A  worm-like  body  (zygote)  soon  develops  which 
is  able  to  bore  through  the  mosquito’s  delicate  stomach  wall,  and  there 
it  assumes  a  globular  form  (oocyst),  gradually  enlarges,  and  in  from  7 
to  20  days,  according  to  the  surrounding  temperature,  becomes  mature. 
Cold  weather  delays  development,  and  warm  weather  favors  it. 

At  maturity  this  body,  or  oocyst,  has  become  divided  up  into 
hundreds  or  thousands  of  slender,  slightly  curved,  elongated  bodies, 
called  “sporozoites.”  The  wall  of  the  mature  oocyst  then  ruptures, 
liberating  the  sporozoites  into  all  parts  of  the  body  cavity  of  the  mos¬ 
quito,  whence  they  make  their  way  into  her  salivary  glands,  and  there 
they  are  ready  to  be  injected  into  and  to  infect  the  next  human  individ¬ 
ual  on  whom  she  feeds.  A  female  infected  mosquito  may  live  6  months, 
and  for  at  least  2  months  subsequent  to  infection  may  be  able  to  trans- 

6 


ANATOMY  OF  THE  MALARIAL  MOSQUITO  .  rrMALF  ma  culiftaitiits  MeigEN 


W.  E  . 


DEEKS 

mit  malaria.  The  adult  form  (imago) 
of  most  species  hibernates,  and  thus 
lives  through  the  winter.  The  devel¬ 
opmental  phase  of  the  parasite  in 
man  is  called  the  “nonsexual  cycle”  ; 
that  in  the  mosquito,  “the  sexual 
cycle.” 

As  stated  above,  there  are  three 
distinct  species  of  the  parasite,  which 
differ  in  their  microscopical  appear¬ 
ance  and  also  in  their  life-histories. 
These  variations  are  partly  responsi¬ 
ble  for  the  difference  in  the  clinical 
symptoms  resulting  from  malaria  in¬ 
fection. 

Tertian  Malaria  (Benign) 

The  form  of  fever  known  as  ter¬ 
tian  malaria  is  caused  by  Plasmodium 
vivax.  This  organism  requires  48 
hours  to  mature  in  the  red  cell,  when 
it  sporulates,  liberating  its  toxins 
and  spores,  which  vary  in  number 
from  16  to  24.  As  the  tertian  or¬ 
ganism  approaches  maturity  in  the 
red  cell,  it  is  larger  than  that  of 
either  of  the  other  species.  The 
normal  dimensions  of  the  red  cell  in 
which  it  develops  become  enlarged, 
and  in  consequence  it  is  frequently 
caught  in  the  minute  blood  vessels 
(capillaries)  of  the  viscera,  where 
sporulation  generally  takes  place. 
The  sporulating  forms  are  therefore 
seldom  seen  in  the  peripheral  blood 
(that  obtained  from  the  finger  or 
ear)  but  must  be  sought  for  in  the 
spleen,  liver  or  other  deep-seated 
viscera. 

Quartan  Malaria  (Benign) 

The  quartan  type  of  malaria 
fever  is  caused  by  Plasmodium  ma- 

7 


MALARIA— ITS  CAUSE.  PREVENTION  AND  CURE 


lariae.  The  organism  differs  from  Plasmodium  vivax ,  in  that  it  takes 
72  hours  to  mature  instead  of  48,  and  produces  at  maturity  from  8  to 
10  spores  only.  It  is  smaller  than  the  tertian  parasite  and  does  not 
enlarge  the  red  cell  in  which  it  develops.  Consequently  the  pre-sporu- 
lating  stage  is  frequently  seen  in  the  peripheral  blood;  it  resembles 
a  “rosette”  or  “daisy”  in  appearance,  with  the  spores  regularly  grouped 
about  the  border  of  the  red  cell  in  which  it  developed. 

Estivo-Autumnal,  Sub-Tertian  or  Malignant-Tertian  Malaria 

This  form  of  malaria  is  caused  by  Plasmodium  falciparum.  In 
Italy,  where  the  seasons  are  well  defined,  quartan  and  tertian  fevers 
are  more  prevalent  in  the  spring  and  winter  months,  and  estivo- 
autumnal  in  the  summer  and  autumn  months — hence  the  term  estivo- 
autumnal.  As  most  of  the  malignant  forms  of  malaria  are  caused  by 
P.  falciparum,  this  type  is  sometimes  called  malignant  tertian,  or  sub- 
tertian,  because  it  has  a  tertian  periodicity  in  its  development  similar 
to  that  of  benign  tertian,  referred  to  above.  Each  estivo-autumnal 
parasite  produces,  on  sporulation,  from  24  to  32  spores.  The  male 
and  female  sexual  forms  (gametes)  also  differ  from  the  gametes  of  the 
other  species,  in  that  they  are  crescent-shaped. 

The  estivo-autumnal  parasite,  during  its  sexual  cycle  in  the  female 
anopheles  mosquito,  is  more  susceptible  to  the  influence  of  cold  than 
the  tertian  and  quartan  types  (frequently  grouped  together  as  the 
benign  fevers),  and  hence  is  not  as  widely  distributed  geographically 
as  the  benign  types,  and  occurs  chiefly  in  the  warmer  regions  of  the 
Tropics  and  Sub-Tropics. 

Incubation  Period 

When  an  individual  is  infected  with  malaria,  several  days  elapse 
before  symptoms  develop.  This  interval  is  called  the  period  of  “ in¬ 
cubation and  varies  considerably  in  length  mainly  according  to  two 
factors:  (a)  the  species  of  parasite  involved,  and  (b)  the  vital  re¬ 
sistance  of  the  patient,  or  the  protective  and  defensive  agencies  of  the 
body.  A  certain  number  of  parasites  must  be  present  in  the  blood  before 
symptoms  appear.  Manson-Bahr  estimates  that  there  must  be  at  least 
one  parasite  to  every  100,000  red-blood  cells,  or  50  parasites  to  every 
cubic  millimeter  of  blood.  The  patient  suffering  from  a  moderately 
severe  attack  probably  has  approximately  500  parasites  to  the  cubic 
millimeter  of  blood,  and  in  very  severe  attacks  20  per  cent  or  more 
of  the  red  cells  may  harbor  parasites — which  is  the  equivalent  of  about 
1,000,000  parasites  for  every  cubic  millimeter  of  blood.  (Normally 
there  are  about  5,000,000  red  cells  to  the  cubic  millimeter.) 


8 


W .  E  .  DEEKS 


The  Plasmodium  vivax  parasites,  which  cause  tertian  fever,  pro¬ 
duce  from  1G  to  20  spores  at  each  sporulation,  every  48  hours,  and 
generally  about  2  weeks  elapse  between  the  period  of  infection  and  the 
production  of  symptoms. 

The  Plasmodium  malariae  parasites,  which  cause  quartan  malaria, 
produce  8  to  10  spores  each,  and  sporulate  every  72  hours,  so  that  the 
period  of  incubation  is  approximately  3  weeks. 

The  Plasmodium  falciparum  parasites,  which  cause  estivo-autumnal 


Fi(i.  2.  Anopheles  eggs  (greatly  magnified)  Fig.  3.  Larvae  of  anopheles  punctipennis 

ii urea u  of  Entomology,  V.  S.  Dept,  of  Agric.,  Wash.,  D.  C. 

fever,  produce  from  24  to  32  spores  each,  and  sporulate  every  48  hours, 
so  that  the  period  of  incubation  is  from  8  to  12  days. 

Some  individuals  are  more  susceptible  to  malaria  infections  than 
others  ;  that  is,  the  power  of  the  body’s  defensive  agents  protecting 
against  disease  varies  in  different  individuals  to  a  marked  degree,  and 
for  many  reasons.  This  variation  has  an  important  influence  in  the 
onset  of  symptoms,  which  may  be  delayed  for  several  days  or  weeks 
by  these  agents’  resistance ;  and  if  that  resistance  is  powerful  enough, 


9 


MALARIA— ITS  CAUSE,  PREVENTION  AND  CURE 


10 


Fig.  4.  Different  stages  in  the  development  of  mosquitoes — cut.ex  (left)  anopheles  (right) 
Vittorio  Ascoii  Note  sitting  'postures  of  adults  on  grass  blades. 


W .  E  .  DEEKS 


the  parasite  or  its  toxin  is  destroyed,  and  no  symptoms  develop-— in 
other  words,  the  patient  is  “immune” 


Fig.  5.  Resting  positions  of  larvae  of  culex  (right)  and  anopheles  (left) 

Bureau  of  Entomology,  U.  S.  Dept,  of  Agric.,  Wash.,  D.  C. 


Symptoms 

At  each  sporulation,  along  with  the  spores,  toxin  or  poison  is 
liberated,  and  this  is  chiefly  responsible  for  the  symptoms  produced. 
The  more  parasites  present,  the  more  red  cells  invaded,  and  the  more 
toxin  produced.  When  there  are  about  50  parasites  to  the  cubic  milli¬ 
meter  of  blood,  the  patients  begin  to  have  feelings  of  lassitude,  nausea, 
headache,  loss  of  appetite,  bone-ache,  vague  muscular  pains,  and  chilly 
sensations.  At  each  succeeding  sporulation  all  these  symptoms  increase 
until  definite  chills  or  rigors  ensue. 

The  symptoms  of  the  two  benign  types  (tertian  and  quartan)  are 
similar,  except  for  periodicity.  Those  of  the  estivo-autunmal  type 
differ  materially  from  those  of  the  benign.  The  rigor  or  chill  charac- 


Fig.  G.  Pupae  of  culex  (left)  anopheles  (right) 
Bureau  of  Entomology,  U.  8.  Dept,  of  Agric.,  Wash.,  D.  C. 


11 


MALARIA — ITS  CAUSE,  PREVENTION  AND  CURE 


teristic  of  the  benign  types  of  fever  lias  three  distinct  phases  which  pass 
gradually  from  one  to  another.  These  are  called  respectively  the 
“cold,”  “hot”  and  “sweating”  stages  of  the  febrile  paroxysm. 

The  Cold  Stage. — This  sets  in  with  chilly  feelings  over  the  body, 
gradually  becoming  more  intense,  so  that  the  teeth  chatter,  the  patient 
shivers,  and  heavy  wraps  or  blankets  are  sought.  Vomiting  is  usually 
present  and  may  be  distressing,  and  in  children  convulsions  are  fre¬ 
quently  seen.  There  is  a  small,  rapid  pulse,  the  skin  is  cold  and  blue, 
and  the  condition  known  as  “goose  skin”  is  present.  During  this  stage, 


Fig.  7.  (Cui.ex)  aedes  soi.licitans  Anopheles  punctipennis 

Bureau  of  Entomology,  V.  S.  Dept,  of  Agric.,  Wash.,  D.  C. 

which  lasts  from  20  to  00  minutes,  the  body  temperature  rises  grad¬ 
ually. 

The  Hot  Stage. — In  this  stage  the  shivering  ceases,  warm  feelings 
ensue,  followed  by  sensations  of  intense  heat  and  distress,  so  that 
blankets  are  discarded.  Headache  is  severe,  the  face  flushed,  pulse 
rapid,  full  and  bounding.  The  respiratory  rate  increases,  vomiting  is 
persistent,  the  skin  hot  and  dry,  and  the  temperature  ranges  from  103 
to  106  F.  This  stage  lasts  from  1  to  2  hours. 

Sweating  Stage. — The  hot  stage  is  succeeded  by  the  sweating  stage, 
in  which  the  patient  breaks  out  into  a  profuse  perspiration  which  liter¬ 
ally  saturates  the  bed  clothing.  The  temperature,  however,  rapidly 
falls  to  normal,  or  sub-normal,  and  all  the  symptoms  gradually  sub¬ 
side  until  the  patient  feels  tranquil  and  well,  and  believes  that  he  is 
able  to  resume  his  work.  This  stage  lasts  from  2  to  4  hours. 

The  duration  of  all  the  three  stages  of  the  chill,  or  rigor,  is  variable, 
but  generally  lasts  from  0  to  10  hours. 


12 


W .  E  .  DEEKS 


The  above  description  of  a  rigor  or  ague  attack  applies  particularly 
to  tertian  and  quartan  infections.  They  differ  from  each  other  mainly 
in  the  fact  that  in  single  infections  the  tertian  chills  recur  every  48 

hours,  while  the 
quartan  chills  re¬ 
cur  evei'y  72  hours. 

The  fever  par¬ 
oxysms  of  estivo- 
autumnal  fever  dif¬ 
fer  considerably 
from  those  of  the 
benign  types.  The 
chills  are  not  so 
definite,  and  often 
partake  of  the 
character  of  mere¬ 
ly  chilly  sensa¬ 
tions,  and  the  dur¬ 
ation  of  the  hot 
stage  lasts  about 
24  hours,  generally  with  some  small  remissions  of  the  fever 
during  that  period.  The  symptoms  during  the  fever  stage  are 
very  similar  to  those  described  in  connection  with  the  benign 
fever,  but  are  probably  more  severe  in  character.  The  toxin 
produced  by  these  organisms  apparently  is  of  a  more  virulent 


Fig.  8.  Anopheles  quadrimaculatus  —  male  and  female 

Bureau,  of  Entomology,  U.  S.  Dept,  of  Agrie.,  Wash.,  D.  C. 


Bureau  of  Entomology,  U.  S.  Dept,  of  Agric.,  Wash.,  D.  C. 

13 


MALARIA— ITS  CAUSE,  PREVENTION  AND  CURE 


nature  than  that  of  the  benign  types.  The  infected  red  cells  tend  to 
become  plugged  in  the  small  blood-vessels  (capillaries)  of  the  viscera — 
intestinal  mucous  membrane,  lungs,  liver,  kidneys,  spleen,  bone  mar¬ 
row  and  the  brain — where  they  sporulate  and  cause  local  injuries  and, 
consequently,  symptoms  referable  to  the  respective  viscera,  the  capilla¬ 
ries  of  which  are  plugged.  The  estivo-autumnal  parasite  is  chiefly 
responsible  for  the  malignant  symptoms  so  often  met  with  in  malaria, 
and  from  this  parasite  the  greater  number  of  fatalities  occurs.  Wher¬ 
ever  these  parasites  localize  and  sporulate,  not  only  inflammatory  con¬ 
ditions  but  frequently  destruction  of  tissue  (necrosis)  will  result. 
Hence  we  may  have  in  these  cases  severe  diarrhea,  bronchitis,  jaundice, 
nephritis  ;  and — when  they  localize  in  the  brain — coma,  delirium,  con¬ 
vulsions,  paralytic  conditions,  etc.,  are  prone  to  develop.  In  order  to 
save  life  among  this  class  of  cases  the  treatment  must  be  heroic  and 
prompt. 

Double  and  Mixed  Infections 

The  symptoms,  referred  to  above,  in  the  different  types  of  malaria 
are  those  of  single  infections.  We  may,  however,  have  double  or  triple 
infections  of  any  species  of  parasite,  or  mixed  infections  of  the  different 
species  of  parasites.  Under  these  circumstances,  the  clinical  picture, 
particularly  the  temperature  charts,  will  vary  greatly.  Thus  we  may 
have  not  only  daily  paroxysms,  but  remittent  or  almost  continuous 
high  temperature,  giving  a  clinical  picture  which  resembles  some  other 
form  of  infectious  disease.  In  all  cases  of  malaria,  however,  careful 
examination  of  the  blood  will  usually  reveal  the  presence  of  parasites, 
but  their  presence  does  not  negative  the  presence  of  some  other  infection 
also. 

R LACK WATER  FeVER 


Another  clinical  manifestation  of  malaria  is  blackwater  fever. 
This  is  a  manifestation  generally  of  chronic  untreated  malaria,  and 
most  authorities  believe  that  the  estivo-autumnal  parasites  are  chiefly 
responsible.  In  this  condition  the  red  cells  of  the  blood  are  dissolved 
( haemolysis )  and  the  colored  contents  ( haemoglobin )  are  liberated  in 
the  blood  stream.  The  destruction  of  red-blood  cells  may  be  so  exten¬ 
sive  that  the  liver,  spleen  and  other  organs  that  normally  take  care  of 
the  haemoglobin  from  worn-out  or  dead  cells  are  unable  to  do  so,  and 
the  excess  amount  of  haemoglobin  is  excreted  by  the  kidneys  in  such 
quantities  that  the  normal  color  of  the  urine  becomes  red,  and  may  be 
in  such  quantity  as  to  give  the  urine  a  black  color — hence  the  term 
“ blackwater .”  The  kidneys  are  also  very  frequently  affected  through 
inflammation  or  obstruction  by  “haemoglobin  casts,”  and  mav  cease 
to  function.  About  10  to  20  per  cent  of  blackwater  fever  cases  die. 


14 


W  .  E  . 


1)  E  E  K  S 


The  prevention  of  blackwater  fever  rests  in  our  ability  to  get  rid  of  the 
malaria  infection. 

The  onset  of  blackwater  fever  generally  begins  with  a  chill,  followed 
by  a  high  temperature,  great  prostration,  thirst,  vomiting,  abdominal 
distress,  aching  loins,  and  great  tenderness  over  the  acutely-enlarged 


Fig.  11.  Resting  position  of  culex  (left)  and  anopheles  (right) 
Bureau  of  Entomology,  JJ.  S.  Dept,  of  Agric.,  Wash.,  D.  C. 


liver  and  spleen.  The  patient  rapidly  becomes  jaundiced,  and  the  urine 
that  is  passed  varies  in  color  from  red  to  black.  Following  the  chill, 
irregular  fever  usually  persists  for  several  days.  The  haemoglobin 
content  of  the  blood  may,  in  severe  cases,  drop  to  10  per  cent,  or  less, 
of  the  normal.  There  may  be  several  attacks  at  intervals  of  one  or 
more  days,  and  they  may  result  from  exposure  to  cold  or  heat;  from 
mental  depression,  fatigue,  malnutrition,  intercurrent  disease;  or  from  a 
dose  of  quinine. 

Immunity 

By  immunity,  in  malaria,  is  meant  that  the  defensive  or  curative 
agents  of  the  body  are  naturally  so  resistant  to  the  parasites  or  their 
toxins — or  have  developed  this  power  of  resistance  to  such  an  extent — 
that  no  infection  occurs,  nor  symptoms  result,  after  the  individual  is 
bitten  by  infected  mosquitoes.  In  the  case  of  malaria  there  is  no 
question  but  that  immunity  can  be  developed  in  some,  if  not  in  all,  indi¬ 
viduals.  We  meet  with  people  apparently  immune  in  all  malaria-infected 
districts  where  tissues  are  so  resistant  that  they  will  take  care  of  any 
form  of  malarial  infection  that  mosquitoes  may  transmit,  so  that  no 
symptoms  will  result.  If  immunity,  more  or  less  complete,  did  not 
exist  in  malaria-infected  districts,  the  population  would  soon  be  deci- 


15 


Plate  A 


SCHEMATIC  REPRESENTATION  OF  MALARIA 

PARASITES 

1  Parasite  in  red  cell 

2  Later  stage 

3  and  4  segmenting  stages 

5  Clump  of  pigment  and  spores  in  red  cell  ready  to  rupture 

6  Female  gamete 

7  Male  gamete 

8  Male  gamete  in  stomach  of  mosquito,  throwing  out  flagella 

Tertian 


I,  2,  3  stages  of  the  parasite  in  the  red  cell 

4  Daisy  form  showing  segmentation 

5  Liberated  spores  with  small  mass  of  black  pigment 

6  Female  gamete 

7  Male  gamete 

8  Male  gamete  in  stomach  of  mosquito,  throwing  out  flagella 

Quartan 


1  Two  small  parasites  on  surface  of  red  cell 

2  Ring  form  of  parasite  partly  in  red  cell 

3  Later  stage  within  cell 

4  Clump  of  pigment  and  spores  in  red  cell  ready  to  rupture 

5  Series  of  spores  (disproportionally  enlarged) 

6  Female  gamete  (crescent) 

7  Male  gamete  (crescent) 

8  Male  gamete  in  stomach  of  mosquito,  throwing  out  flagella 

Aestivo-autumnal 


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Aestivo  -aatumnal 


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8 


Mabel  Hedge,  Pixx 


PLATE  A 


(A)  Nonsexual  cycle  in  the  human  host. 

(a)  Section  of  human  skin  showing 
different  layers  with  loops  of 
blood  vessels  (in  red)  and  se¬ 
cretory  ducts. 

(b)  Blood  stream. 

1.  Head  of  mosquito  with  proboscis 
puncturing  skin  and  injecting 
sporozoites  into  blood  vessels. 
(The  salivary  gland  and  duct 
shown  in  green.) 

2.  Malarial  sporozoite. 

3.  Sporozoite  entering  red-blood  cell. 

4.  Red  cell  containing  “signet-ring” 
form  of  parasite. 

5.  Developing  parasite  in  red  cell. 

6.  Parasite  divided  into  spores. 

7.  Group  of  spores  after  sporulation, 
most  of  which  enter  other  red- 
blood  cells  and  continue  the  non¬ 
sexual  cycle  of  development. 

8.  Red  cell  showing  male 
gamete. 

9.  Male  gamete  fully  de¬ 
veloped. 

10.  Red  cell  showing  fe¬ 
male  gamete. 

11.  Female  gamete  fully 
developed. 

12.  Mosquito’s  proboscis 
withdrawing  infected 
blood. 


a 


PLATE  B 


B 


(B)  Sexual  cycle  in  the  anopheles  mos¬ 
quito. 

(c)  Stomach  wall  of  mosquito. 

(d)  Stomach  of  mosquito. 

13.  Female  gamete  in  mosquito’s 
stomach,  throwing  off  polar  body 
for  reception  cf  male  element. 

14.  Male  gamete  in  mosquito’s  stom¬ 
ach,  throwing  off  flagella. 

15.  Flagellum  from  male  entering  fe¬ 
male  gamete. 

1(>.  Fertilized  female  gamete. 

17.  Zygote,  or  worm-like  stage  of  fer¬ 
tilized  gamete,  boring  into  the 
stomach  wall  of  mosquito. 

18.  Early  stage  of  oocyst. 

19.  Later  stage  of  oocyst,  showing 
cell  division. 

20.  Mature  oocyst  filled  with  sporozo¬ 
ites  rupturing  into  body  cavity  of 
mosquito. 

21.  Section  through  salivary  gland 
showing  sporozoites  ready  to  be 
injected  into  human  subject  by  fe¬ 
male  mosquito. 


PLATE  B 


Severe  aestivo-autumxal  ixfectiox  with  de- 

VELOPIXG  GAMETE  IX  CENTER  OF  THE  FIELD 

After  photograph  by  J.  G.  Thomson 


Schematic  represextatiox  of  ixfected  sali¬ 
vary  GLAND  SHOWING  ELOXGATED  SPOROZOITES  IX 
THE  CELLS  (pIXK)  AXD  THE  DUCTS  (PALE  BLUE). 
The  PIXK  CELLS  SHOW  BLUE  XUCLEI. 


Mabel  Hedge,  Pixx. 


PLATE  C 


W .  E  .  DEEKS 


mated.  The  factors  which  bring  about  immunity  to  malaria  are  un¬ 
known  ;  if  they  were  known,  the  problem  of  its  eradication  would  soon 
be  solved.  It  must  also  be  kept  in  mind  that  immunity  developed  against 
one  species  of  parasite  does  not  prevent  infection  by  other  species. 

In  malaria-infected  districts  we  meet  with  a  certain  percentage  of 
people  whose  blood  is  apparently  free  from  the  parasites,  although 
those  same  people  are  constantly  exposed  to  malaria  infection.  Un¬ 
doubtedly,  in  most  cases  they  have  acquired  the  disease  in  childhood 
and  developed  agencies  in  the  body  which  prevent  reinfection,  after  the 
manner  of  the  immunity  developed  in  people  who  have  had  scarlet 
fever,  measles,  whooping  cough,  etc.  On  the  other  hand,  a  large  per¬ 
centage  of  the  population,  particularly  in  the  rural  districts,  have 
malarial  organisms  in  their  blood.  This  infection  interferes  with  their 
efficiency,  and  under  certain  conditions  becomes  acute,  producing  symp¬ 
toms  which  incapacitate  them  for  work.  Malarial  organisms  may 
exist  in  sufficient  number  in  the  blood,  in  these  latent  cases,  to  infect 
mosquitoes  that  feed  on  them,  and  they  may  thus  be  able  to  communi¬ 
cate  the  infection  to  others.  In  other  words,  latent,  cases  are  reservoirs 
of  infection  and  a  menace  to  the  community  in  which  they  live. 

In  these  latent,  or  chronic,  cases  there  is  anaemia  and  consequently 
poor  resistance,  and  such  cases  are  thus  liable  to  develop  other  diseases. 

Treatment 

Any  method  of  treatment,  to  be  efficacious,  must  care  for  not  only 
the  acute  primary  infections,  but  also  the  chronic  relapsing  cases.  The 
prevention  and  treatment  of  blackwater  fever  necessitates  careful 
consideration. 

Primary  Infections 

Recent  work  by  Yorke  and  Macfie  has  shown  that  primary  infections 
in  individuals  otherwise  healthy  are  readily  cured  if  promptly  and 
efficiently  treated.  When  it  has  been  determined  that  malaria  infec¬ 
tion  exists  in  an  individual,  administration  of  quinine  in  some  form  and 
in  some  way  is  indicated.  Before  its  administration  is  begun — except 
in  malignant  cases  where  especially  prompt  measures  are  necessary — 
a  preliminary  dose  of  3  grains  of  calomel,  followed  in  6  hours  by  1  to  2 
ounces  of  magnesium  sulphate  serves  a  useful  purpose  and  facilitates 
the  cure.  A  couple  of  hours  after  the  calomel  has  been  given,  the 
administration  of  quinine  can  be  initiated.  The  amount  to  be  given 
will  depend  largely  on  the  age,  sex  and  weight  of  the  individual,  and 
also  on  the  nature  and  the  severity  of  the  symptoms.  For  the  average 
individual  with  moderately  severe  symptoms,  40  to  45  grains  of  quinine 

17 


MALARIA— ITS  CAUSE,  PREVENTION  AND  CURE 


daily,  divided  in  2  or  3  doses  will  suffice,  and  this  treatment  should  be 
continued  until  the  temperature  is  normal.  A  second  dose  of  magnesium 
sulphate  should  then  be  given,  and  the  quantity  of  quinine  should  be 
reduced  to  30  grains  daily  divided  in  2  or  3  doses ;  and  this  dosage 
should  be  continued  until  the  patient’s  temperature  has  remained  normal 
for  from  5  to  7  days. 

In  cases  of  malaria,  a  generous  diet  should  be  ordered  as  soon  as 
the  desire  for  food  returns,  and  the  patient  must  not  be  permitted 
to  return  to  work  before  his  appetite  has  returned  and  he  feels  physi¬ 
cally  fit. 

Other  disease  complicating  conditions  may  delay  the  convalescence, 
and  should  therefore  be  considered  in  the  treatment.  Subsquently 
the  patient  should  be  advised  to  continue  10  grains  of  quinine,  daily, 
for  at  least  two  wreeks  longer,  or  if  there  is  much  anaemia  present,  a 
combination  of  quinine,  iron  and  strychnine  is  indicated  for  the  same 
length  of  time,  or  longer.  A  suitable  combination  is  Aiken’s  tonic 
tablets,  each  one  containing  the  following  components : 


Quinine  Sulphate .  1  grain 

Acid  Arsenous  .  1/50  “ 

Strychnine  Sulphate .  1/50  “ 

Reduced  Iron  .  2/3  “ 

Ext.  Gentian  .  1/4  “ 


In  the  vast  majority  of  cases,  if  this  method  of  treatment  be  care¬ 
fully  followed  out,  there  will  be  no  subsequent  r/lapse.  We  find  that 
children  can  tolerate  larger  doses  of  quinine  proportionately  to  their 
age,  than  adults.  To  a  child  under  1  year  of  age,  )/2  to  1  grain  can 
be  given  3  times  daily,  and  in  older  children  the  dose  can  be  increased  1 
grain  for  each  year  of  age,  up  to  8  or  10  years.  In  malignant  cases 
5  grains  hypodermically  may  be  given  immediately,  and  repeated  if 
necessary ;  after  this  it  can  be  given  by  mouth. 

Some  authorities  (Bass’s  Standard  Treatment)  believe  that  30 
grains  daily  are  sufficient,  as  long  as  there  is  fever,  to  bring  about  con¬ 
valescence,  and  that  after  the  fever  ceases  10  grains  should  be  given 
daily  for  a  period  of  2  months  or  longer,  according  to  its  chronicity. 

The  writer  believes  that  in  the  more  temperate  climates  quinine  is 
not  tolerated  as  well  as  in  the  warmer  climates,  and  that  in  the  colder 
climates  the  drug  is  more  apt  to  produce  symptoms  of  discomfort  such 
as  ringing  in  the  ears,  deafness,  nervousness,  etc.  These  symptoms 
may  be  prevented,  or  relieved  to  some  extent,  by  bromides. 

It,  is  immaterial,  in  the  ordinary  cases  of  malaria,  whether  the 
quinine  be  given  in  solid  or  liquid  form,  so  long  as  it  is  swallowed,  re- 


18 


W  .  E  .  DEEKS 


Fig.  12.  Digestive  tract  of  Anoj)heles,  the 

STOMACH  OF  WHICH  IS  COVERED  WITH 
NUJIEROUS  ZYGOTES,  OR  OOCYSTS,  OF 

Plasmodium  falciparum:  c,  cloaca; 
mt,  malphigian  tubules;  o,  oocyst; 
s,  stomach  ;  sb,  sucking  bi.adders,  or 
pumping  organ;  sg,  salivary  gland 
(Stitt) 


tamed  and  absorbed.  If 
vomiting  occurs,  quinine 
should  be  administered  hypo¬ 
dermically. 

Acute  Malignant  Cases 

We  often  meet  with  acute 
cases  in  which  the  treatment 
previously  described  will  not 
save  the  life  of  the  patient. 
Vomiting  may  be  persistent, 


Fig.  13.  Stomach  of  anopheles 

SHOWING  VERY  MANY  DE¬ 
VELOPING  OOCYSTS 


and  the  patient  may  be  unable  to  retain  anything.  There  may  be 
coma,  delirium,  convulsions,  paralysis,  etc.,  resulting  from  the  localiza¬ 
tion  of  the  parasites  in  the  small  blood-vessels  (capillaries)  of  the 
brain,  and  the  patient  may  be  unconscious  or  otherwise  unable  to 
swallow.  In  these  cases  quinine  must  be  administered  by  means  of  the 
hypodermic  needle,  either  intramuscularly  or  intravenously.  The 
writer  has  also  used  the  deep-subcutaneous  method  with  gratifying  re¬ 
sults.  By  this  method  the  needle  should  go  down  to  the  muscle  sheath, 
but  not  into  the  muscles.  The  above-mentioned  methods  of  adminis¬ 
tration  require  professional  skill,  and  should  be  used  only  by  a  physi¬ 
cian  or  a  trained  nurse. 


19 


MALARIA— ITS  CAUSE,  PREVENTION  AND  CURE 


Suitable  preparations  of  quinine  for  hypodermic  administration 
are  now  obtainable,  and  should  be  kept  always  ready  for  use  in  districts 
where  this  class  of  cases  occurs.  These  preparations  should  be  as 
nearly  neutral  as  possible,  or  very  faintly  acid  (Carter).  A  solution 
of  excessive  acidity  will  prove  very  painful  and  tend  to  cause  destruc¬ 
tion  of  the  tissue  where  it  is  injected.  The  solutions  for  hypodermic 
purposes  should  also  be  properly  diluted  and  slowly  injected,  and  the 
location  must  be  subsequently  massaged,  warm  applications  being  used 
to  accelerate  absorption.  The  buttocks  are  to  be  preferred  for  intra¬ 
muscular  injections.  For  deep-subcutaneous  injections  the  preferred 
sites  are  the  buttocks,  posterior  to  the  pectoral  muscle,  or  over  the 
abdomen  down  to,  but  not  into,  the  muscle  sheath.  For  these  injections 
the  dilutions  should  be  1  of  quinine  to  from  5  to  10  of  diluent.  For 
intravenous  use  the  dilution  should  be  greater — 1  of  quinine  to  from 
10  to  20  of  diluent;  and  some  authorities  advise  a  dilution  of  1  gram 
of  quinine  to  100  and  even  200  cc.  of  normal  saline  solution.  It  is 
very  important,  in  giving  intravenous  injections,  that  the  needle  be 
very  fine  and  the  injections  made  very  slowly. 

In  malignant  cases,  when  any  of  these  methods  are  used,  15  grains 
can  be  given,  and  can  be  repeated  if  necessary  in  3  or  4  hours,  until 

3  or  4  injections  shall  have  been  given.  In  the  case  of  intramuscular 
injections  it  is  not  wise  to  give  more  than  7  j/2  grains  in  one  location, 
and  in  subsequent  administrations  a  location  should  be  selected  at  least 

4  inches  from  the  site  of  the  original  injection.  This  precaution  will 
tend  to  prevent  the  development  of  an  abscess.  As  soon  as  the  patient 
can  tolerate  quinine  given  by  the  stomach,  hypodermics  should  be  dis¬ 
continued  and  the  quinine  should  be  given  by  mouth. 

Chronic  and  Relapsing  Cases 

In  these  cases  there  is  a  different  clinical  picture,  and  the  treatment 
must  be  varied  accordingly.  The  patient  has  a  chronic  malaria  infec¬ 
tion  because: 

(1)  The  primary  infection  was  never  cured,  not  enough  quinine 
having  been  taken  over  a  sufficient  period  of  time. 

(2)  The  patient  has  some  other  complicating  disease  or  organic 
infection  which,  in  itself,  is  sufficient  to  lower  his  resistance,  and  thus 
prevent  the  defensive  agencies  of  the  body  from  developing  immunity. 

(3)  The  patient  is  suffering  from  malnutrition  resulting  from  food 
deficient  in  quantity,  quality,  or  both. 

In  the  treatment  of  cases  of  chronic  malaria  these  defects  must  be 
taken  into  consideration,  and  corrected  as  far  as  possible.  In  these 
chronic  cases  there  is  not  only  blood-destruction  but  impoverishment 

20 


W .  E  .  DEEKS 


of  the  coloring  matter  of  the  red-blood  cells,  as  well.  The  treatment 
as  described  in  primary  infections  should  be  given,  but  during  the 
convalescent  period  the  quinine,  or  the  combination  of  it  with  iron  and 
arsenic,  should  be  continued  over  3  or  4  months  until  the  convalescence 
of  the  patient  is  completely  established.  In  some  of  the  more  chronic 
relapsing  cases  a  change  of  climate  may  prove  to  be  very  beneficial. 

Treatment  of  Blackwater  Fever 

In  these  cases,  owing  to  the  distressing  thirst  and  vomiting,  imme¬ 
diate  relief  can  best  be  obtained  by  injecting  8  to  10  ounces  of  warm, 
normal  saline  solution  into  the  tissue.  (Normal  saline  solution  is  made 
by  dissolving  a  teaspoonful  of  common  table-salt  in  a  pint  of  warm 
water  that  has  been  boiled  and  allowed  to  cool  to  body  temperature.) 
If  suitable  apparatus  is  not  available  for  making  this  solution,  a  cleans¬ 
ing  enema  should  first  be  given,  and  then  6  to  8  ounces  of  normal  saline 
can  be  slowly  introduced  into  the  bowel  through  a  high  rectal  tube. 
This  treatment  can  be  repeated  every  3  or  4  hours ;  it  will  relieve  the 
thirst  and  vomiting. 

After  the  urine  becomes  normal  in  color  and  the  stomach  can  toler¬ 
ate  fluids,  a  bland  liquid  diet  can  be  taken  by  mouth.  When  the  acute 
symptoms  subside,  a  small  dose  of  quinine  (2  or  3  grains)  should  be 
given  hypodermically.  If  this  is  not  followed  by  a  reappearance  of 
black  water  in  3  or  4  hours,  another  hypodermic — of  5  grains — can 
be  given.  Then,  if  that  is  tolerated  without  any  disagreeable  results, 
a  small  dose  (5  grains)  of  quinine  3  times  daily  can  be  given  by  mouth, 
and  the  amount  can  be  gradually  increased  until  the  treatment  is  similar 
to  that  described  for  primary  infections. 

Dr.  A.  A.  Facio,  of  Port  Limon,  Costa  Rica,  has  obtained  excellent 
results  in  these  cases  by  giving  intramuscular  injections  of  3  grains  of 
caffeine  sodio-benzoate  twice  daily  for  2  or  3  days,  and  then  once  daily 
until  the  jaundice  disappears. 

Dr.  Crawford,  of  Sasser,  Georgia,  recommends  an  intravenous  injec¬ 
tion  of  20  cc.  of  anti-streptococcus  serum,  to  be  repeated  if  necessary. 

Unfortunately,  from  10  to  20  per  cent  of  blackwater  cases  die. 
In  some  of  these  cases,  the  red  cells  continue  to  dissolve,  and  the 
patients  continue  to  pass  black  urine  until  they  literally  bleed  to  death. 
In  other  cases,  the  secreting  tubules  of  the  kidneys  become  diseased,  and 
the  coloring  matter  of  the  blood  (haemoglobin)  forms  casts  in  the  tu¬ 
bules,  the  secretion  and  passage  of  urine  being  prevented.  These  latter 
cases  develop  uraemia  and  die  shortly  after  the  suppression  of  urine. 

We  know  of  no  remedies  to  prevent  or  relieve  such  conditions.  The 
importance  of  seeking  skilled  professional  advice  in  the  treatment  of 


21 


MALARIA— ITS  CAUSE,  PREVENTION  AND  CURE 


all  severe  forms  of  malaria  must  be  stressed.  Delay  in  seeking  advice 
may  prove  fatal  to  the  patient. 

Quinine  Prophylaxis 

Recent  developments  in  the  study  of  malaria  would  seem  to  indi¬ 
cate  that  quinine  given  to  a  person  exposed  to  malaria  will  not  prevent 
infection,  but  that  if  it  be  taken  routinely  during  periods  of  exposure, 
and  infection  occurs,  the  routine  administration  of  quinine  in  sufficient 
quantities  for  from  10  to  11  days  after  infection,  will  prevent  the  devel¬ 
opment  of  symptoms.  In  other  words,  quinine  has  no  effect  on  the  sporo¬ 
zoites  injected  into  the  blood  by  infected  mosquitoes;  and  some  author¬ 
ities  believe  that  it  has  no  effect  on  the  spores  ( schizonts )  liberated 
in  the  blood  stream  after  sporulation,  but  only  on  the  organisms 
(trophozoites)  enclosed  in  the  red-blood  cells. 

It  would  seem  useless,  therefore,  to  give  quinine  to  prevent  malarial 
infection.  However,  as  soon  as  infection  manifests  itself  by  the  devel¬ 
opment  of  symptoms,  quinine  should  be  given  in  generous  quantities. 
Under  these  conditions  there  is  a  “primary  infection,”  which  should 
be  treated  as  such.  If  insufficient  quinine  is  given  for  an  insufficient 
period  the  affection  becomes  chronic,  and  therefore  difficult  to  cure, 
and  the  possibility  of  the  development  of  blackwater  fever  occurs.  In 
communities  where  infection  is  widespread  the  administration  of  quinine 
is  strongly  indicated,  and  it  should  be  given  daily  or  interruptedly,  over 
long  periods.  This  is  particularly  to  be  recommended  if  infected 
anopheles  mosquitoes  are  very  numerous  in  the  neighborhood  of  dwell¬ 
ings.  Controlling  the  development  of  the  infection  will  prevent  a  great 
deal  of  sickness,  and  also  tend  to  prevent  mosquitoes  from  becoming 
infected,  so  that  the  spread  of  the  disease  will  be  limited. 

It  is  advisable  to  give  consideration  both  to  the  preparations  of 
quinine  that  should  be  used,  and  to  the  best  methods  of  administration. 
As  to  the  first — we  may  administer  quinine  in  the  form  of  the  insoluble 
alkaloid,  or  its  salts,  the  sulphate,  bi-sulphate,  hydrochloride,  or  bi¬ 
hydrochloride.  Some  also  recommend  the  tannate,  tartrate,  or  lactate 
salts,  as  well  as  euquinine  (an  ethyl-ester  of  quinine-carbonic  acid). 
This  latter  group  of  preparations  is  practically  insoluble,  hence  almost 
tasteless,  and  consequently  of  value  in  selected  cases.  The  quinine  alka¬ 
loid  is  also  practically  insoluble.  The  sulphate  is  soluble  to  the  extent 
of  1  part  in  800  parts  of  water,  and  the  hydrochloride  to  the  extent  of 
1  part  in  *35  parts  of  water.  When  acid  is  present  in  excess,  these  salts 
enter  into  solution  readily:  the  bisulphate  1  in  18  parts,  and  the  bi- 

hvdrochloride  in  less  than  its  own  weight  in  water. 

*  © 

For  hypodermic  use,  the  bihydrochloride  salt  is  to  be  preferred  be- 


22 


W .  E  .  DEEKS 


‘ 


■> 


Fig.  14.  Temperature  chart  of  typical  tertian  malaria  tem¬ 
perature  AND,  BENEATH,  THE  STAGES  OF  THE  MALARIA 
ORGANISMS  CORRESPONDING  TO  THE  FEBRILE  CURVE 


cause  of  its  solubility,  but  if  the  solution  contains  an  excess  of  acid 
the  injection  is  very  painful.  It  is  better,  therefore,  to  use  the  neutral 
salt,  well  diluted ,  at  body  temperature,  and  to  administer  it  very  slowly. 

From  observations  made  recently  in  our  hospitals,  the  insoluble 
salts  of  quinine  are  as  effective  therapeutically  as  the  soluble  prepara¬ 
tions.  It  is  generally  believed,  however,  that  quinine  in  solution  acts 
more  quickly  than  in  the  insoluble  preparations.  Solutions  must  also 
be  used  with  patients  who  are  unable  to  swallow  pills,  tablets  or  cap¬ 
sules.  Care  must  always  be  taken  to  see  that  pills  and  tablets  arc 
readily  friable,  for  otherwise  they  will  pass  through  the  alimentary 
tract  without  being  absorbed. 

Undoubtedly  the  intravenous  use  of  quinine  is  indicated,  and  is  to 
be  preferred,  when  prompt  action  is  necessary  in  order  to  save  life. 
Howell  claims  that  it  takes  about  half  a  minute  for  a  circulating  par¬ 
ticle  of  blood  to  return  to  any  one  starting  point,  and  as  tbe  intra¬ 
venous  injection  requires  a  longer  time  than  this,  all  infected  circulat- 


23 


34 -£L 


MALARIA— ITS  CAUSE,  PREVENTION  AND  CURE 


24 


W .  E  .  DEEKS 


25 


16.  Properly  screened  house 


MALARIA— ITS  CAUSE,  PREVENTION  AND  CURE 


ing  cells  are  brought  into  direct  contact  with  the  quinine  solution 
during  the  period  of  injection,  and  only  those  escape  which  are  plugged 
in  the  capillaries  of  the  viscera. 

Prevention  of  Malaria 

To  avoid  being  bitten  by  malaria-infected  mosquitoes,  is  to  prevent 
malaria.  The  female  anopheles  mosquito  lays  her  eggs  on  the  surface 
of  fresh  or  brackish  water  in  star,  triangle  or  ribbon  patterns,  about 
100  or  more  during  each  egg-laying  period.  The  temperature  of  the 
water  will  largely  determine  the  length  of  time  (12  to  72  hours) 
in  which  the  eggs  hatch  into  larvae  or  “wiggle-tails.”  The  larvae  feed 
on  all  forms  of  vegetable  matter,  and  complete  this  stage  of  their 
growth  in  approximately  from  3  to  8  days.  They  then  enter  the 
resting,  or  pupa,  stage  during  which  time  they  complete  their  develop¬ 
ment  and  emerge  as  adult  mosquitoes,  or  imagoes,  in  from  2  to  3  days. 
The  length  of  time  necessary  for  the  egg  to  reach  maturity,  from 
the  time  it  is  laid,  is  from  1  to  3  weeks  according  to  the  temperature 
of  the  water  and  other  factors  affecting  nutrition. 

Cold  retards  and  warmth  hastens  the  development.  About  21  hours 
after  mating  and  fertilization  the  adult  female  seeks  a  meal  of  warm 
blood  to  mature  the  eggs.  If  she  feeds  upon  malaria-infected  individ¬ 
uals  and  ingests  the  sexual  malaria  parasites  she  becomes  infected, 
and  in  about  10  or  12  days  is  ready  to  infect  the  next  individual  on  whom 
she  feeds.  The  mosquito’s  first  “feed”  of  warm  blood  does  no  harm 
to  the  individual  bitten,  but  when  the  insect’s  salivary  glands  are  full 
of  the  young,  malaria  rod-like  spores  ( sporozoites )  she  is  dangerous. 
Our  efforts,  therefore,  must  be  directed  to  prevent  her  feeding  upon  us, 
or  to  encompass  her  destruction.  Sanitary  measures  for  prevention 
of  malaria  are  directed,  first,,  toward  protection  against  being  bitten, 
and  secondly,  toward  destruction  of  the  adult  mosquitoes  during  their 
developmental  or  larval  stage. 

The  female  anopheles  mosquitoes  feed  almost  always  between  sunset 
and  sunrise.  To  avoid  being  bitten  by  them,  we  must  protect  ourselves 
especially  during  these  hours.  The  most  satisfactory  method  of  pro¬ 
tection  is  to  live  in  an  effectively  screened  house.  The  writer  believes 
that  a  poorly  screened  house  is  worse  than  one  entirely  unscreened, 
as  it  forms  a  mosquito  trap  from  which  the  mosquito,  having  gained 
entrance,  has  difficulty  in  escaping,  and  thus  repeatedly  feeds  on  the 
inmates,  if  water  is  available.  Very  few  carpenters  employed  for  the 
screening  of  buildings  thoroughly  understand  the  requirements,  and  con¬ 
sequently  their  work  is  imperfect.  It  is  very  important  to  have  a 
skilled  inspector  examine  this  work  if  satisfactor}T  results  are  to  be 
insured. 


26 


W .  E  .  DEEIvS 


A  mosquito-proof  house  is  one  which  no  mosquitoes  can  enter 
except  through  the  doors,  and  these  should  always  be  protected  by 
porches  screened  separately  from  the  veranda  or  main  entrance  to  the 
house.  The  porches  should  be  on  the  windward  or  exposed  side  of  the 
house,  whenever  possible,  and  the  doors  must  be  constructed  to  swing 
outward.  The  windows  should  be  solidly  and  securely  screened — the 
screens  immovable  and  flush  with  the  outside  walls  of  the  house.  The 


Fig.  17.  Effective  mosquito  bar  ( FUlleborn ) 


windows,  moreover,  should  be  of  the  French  type,  opening  inward,  so 
as  to  admit  of  being  easily  cleaned.  Shades,  shutters,  etc.,  should  be 
arranged  on  the  inside  of  the  screening. 

A  ceiling  is  absolutely  necessary.  It  is  practically  impossible  to 
effectively  screen  a  house  that  has  no  ceiling.  Also,  a  ceiling  prevents 
overhead  heat-radiation  and  consequent  discomfort,  particularly  in 
houses  with  metal  roofs.  Seasoned  lumber  should  always  be  used  in 
the  construction  of  wood  houses,  or  cracks  will  develop  as  the  lumber 
dries,  and  thus  render  the  screening  measure  ineffective.  The  screens 
should  have  a  mesh  of  not  less  than  16  to  18  meshes  to  the  inch,  ac¬ 
cording  to  the  gauge  of  the  wire  used  in  their  construction.  For  the 
former  size  the  wire  gauge  should  have  a  diameter  of  .016  of  an  inch; 
for  the  latter  .010125  (English  standard).  The  gauze  material  should 
be  of  bronze,  galvanized  iron,  copper,  or  monel  metal.  When  exposed 
to  sea  air,  pure  copper  or  monel-metal  wire  alone  is  durable.  The 
copper  should  not  contain  more  than  one-half  of  one  per  cent  of  iron. 
A  screened  house  having  been  properly  constructed,  it  is  very  important 


27 


MALARIA— ITS  CAUSE,  PREVENTION  AND  CURE 


for  the  inmates  to  realize  that  they  must  remain  behind  the  screens 
from  sunset  to  sunrise,  or  take  other  measures  for  protection,  such  as 
the  use  of  repellants. 

Next  best  to  a  screened  house,  the  most  effective  method  of  pro¬ 
tection  will  be  mosquito  bars  over  the  beds.  These  also  call  for  careful 
construction.  They  should  never  be  less  than  3  feet  in  width — other¬ 
wise  it  is  practically  impossible  to  prevent  some  part  of  the  body  from 
coming  in  contact  with  the  net  and  thus  being  bitten  through  its 
meshes.  The  bars  should  be  constructed  and  suspended  so  as  to  take 
the  form  of  an  inverted  sack,  the  open  end  being  securely  fastened 
to  the  floor,  or  carefully  tucked  beneath  the  mattress  of  the  bed. 

According  to  Dr.  Coogle,  creosote  sprayed  throughout  the  dwelling 
is  a  satisfactory  repellant  for  mosquitoes.  This  appears  to  be  a  good 
temporary  measure  in  dwellings  that  do  not  lend  themselves  to  effective 
screening;  or  if  an  individual  is  liable  to  be  exposed  at  night,  then  some 
repellant  sprayed  on  the  clothing  will  prove  temporarily  effective.  In 
a  similar  manner  other  essential  volatile  oils  are  recommended,  but 
they  are  not  very  satisfactory. 

Whenever  possible,  mosquitoes  should  be  destroyed  or  their  breed¬ 
ing  prevented.  Any  attempt,  to  destroy  all  adult  mosquitoes  is  futile. 
Those  accessible  in  the  house  can  be  destroyed,  when  “swatting”  proves 
a  satisfactory  measure;  and  as  they  usually  select  dark  places  and 
avoid  light,  colored  surfaces,  they  can  easily  be  discovered.  The  ser¬ 
vices  of  children  can  readily  be  enlisted  for  this  purpose. 

Efforts  therefore  must  be  directed  to  prevent  mosquitoes  from  breed¬ 
ing,  or  to  destroy  the  larvae.  As  they  lay  their  eggs  in  water  collec¬ 
tions  of  all  sorts^ponds,  streams,  holes,  seepage  areas,  discarded 
utensils,  cans,  etc. — in  fact,  in  any  place  that  will  hold  water  or  mois¬ 
ture  for  a  week,  the  task  of  entirely  preventing  them  from  breeding  is 
gigantic,  and  the  best  that  one  can  hope  for  is  a  reasonable  degree 
of  control.  In  towns  and  cities  there  is  no  excuse  for  permitting  mos¬ 
quitoes  to  breed  if  ordinary  vigilance  is  used  and  efficient  sanitary 
measures  are  taken. 

In  villages  and  rural  communities,  reasonable  control  measures  are 
almost  always  possible,  and  should  be  attempted.  All  useless  rubbish, 
discarded  cans,  bottles,  etc.,  which  will  hold  water  for  a  week  should  be 
destroyed  or  buried.  Still  water  such  as  pools,  etc.,  should  be  drained 
or  filled  whenever  possible.  When  this  is  impossible  they  should  be 
treated  periodically  with  crude  oil  or  some  of  its  derivatives,  Paris 
green,  etc.  There  are  a  great  many  combinations  of  crude  oil  which 
are  serviceable.  In  itself,  it  is  too  thick  to  spread  in  a  satisfactory 
manner  over  the  surface  unless  it  is  diluted  with  kerosene,  castor  oil 
or  similar  preparation.  Good  results  are  obtained  by  heating  crude 

28 


W .  E  .  DEEKS 


oil  before  spraying  it.  Paris  green  should  be  mixed  with  any  form  of 
dust,  in  the  proportion  of  1  to  100,  and  thrown  into  the  air  on  the 
windward  side  of  the  pond.  It  will  thus  be  distributed  over  the  water 
in  a  thin  layer.  One  pound  of  the  mixture  is  sufficient  to  cover  approx¬ 
imately  1,000  square  feet  of  water  surface.  The  method  proves  very 
effective  in  destroying  the  larvae  of  anopheles  mosquitoes,  as  they  feed 
from  the  surface  of  the  water  and  thus  are  readily  poisoned.  The 
method  is  particularly  satisfactory  as  compared  with  the  oiling  of 
ponds  or  pools  covered  with  vegetation ;  the  powder  settling  on  the 
leaves  is  gradually  spread  to  the  water  beneath. 

In  ponds  or  pools  which  cannot  be  drained,  and  which  are  com¬ 
paratively  free  from  vegetation,  fish-stocking  with  minnows  is  particu- 


29 


MALARIA— ITS  CAUSE,  PREVENTION  AND  CURE 


larly  efficient.  Gambusiae  are  generally  used  for  this  purpose,  as  they 
are  “top-feeders”  and  consume  large  numbers  of  larvae  from  the  sur¬ 
face.  The  edges  of  the  pond  should  be  kept  clear  of  vegetation  and 
the  surface  free  from  floatage.  Wild  shrubbery  or  rank  vegetation 
should  not  be  permitted  to  grow  near  the  habitations,  but  should  be  cut 
from  time  to  time  to  prevent  the  harboring  of  mosquitoes. 

The  water  supply  is  important.  When  carefully  banked  wells  are 
not  available  and  cisterns  must  be  used,  they  should  be  carefully 
screened.  This  screening  necessitates  a  mosquito-proof  cover,  as  well 
as  aeration.  Reinforced  concrete  is  the  best  material  for  construction, 
as  it  is  permanent  and  inexpensively  maintained.  If  a  solid  roof  is 
constructed  an  automatic  closing-inlet  is  necessary,  and  a  screened 
space  beneath  the  roof  for  purposes  of  ventilation. 

Special  attention  should  be  given  also  to  latrines,  to  see  that  they 
are  properly  constructed  and  kept  in  a  sanitary  condition.  This  is 
necessary  to  prevent  not  only  the  breeding  of  mosquitoes,  but  the  access 
of  flies,  which  may  communicate  typhoid  fever,  dysentery,  etc.,  as  they 
feed  from  latrines  which  frequently  contain  disease-producing  germs  ; 
then  the  flies  visit  food  supplies,  expel  the  contents  of  their  infected 
probosces,  and  feed  again.  In  localities  where  malaria  is  endemic, 
hookworm  disease  generally  prevails  also,  and  the  two  conditions  are 
frequently  present  in  the  same  individual.  As  hookworm  disease  pro¬ 
duces  anaemia,  and  since  this  lowers  the  resistance  of  the  patient,  the 
cure  of  the  associated  malaria  infection  is  rendered  much  more  difficult 
than  otherwise  would  be  the  case. 

In  general,  it  may  be  said  that  malaria  and  hookworm  disease  are 
the  handmaids  of  poverty  and  ignorance,  and  that  their  eradication 
depends  on  the  development  of  prosperity  among  the  inhabitants  and 
the  spread  of  knowledge  of  the  causation  and  prevention  of  these 
diseases.  Therefore,  in  a  community  any  efforts  dii-ected  toward  the 
betterment  of  these  conditions  will  tend  to  lower  the  incidence  of  the 
diseases  mentioned. 

Not  only  should  schools  be  established  in  the  communities  where 
these  diseases  prevail,  but  a  part  of  the  school  curriculum  should  be 
devoted  to  the  teaching  of  the  causation  of  the  prevailing  endemic 
and  epidemic  diseases,  and  the  explanation  of  sanitary  methods  neces¬ 
sary  for  their  prevention  and  cure.  In  this  way,  besides  having  one 
sanitary  officer  in  a  district,  every  school  child,  and  through  them  their 
parents,  might  become  sanitary  officers  for  the  protection  of  themselves 
and  the  community  at  large.  We  should  endeavor  to  help  the  individual 
and  to  encourage  him  to  help  himself.  Thus,  and  thus  only,  may  we 
hope  for  efficient  control  and  for  the  ultimate  eradication  of  malaria 
and  hookworm  disease. 


30 


•  ■ 


N 


